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• ENVIRCNMF=AL !MA-E-4 +DIVISION 0 <br /> APPLICATION FOR UNDERGRCi.-NP TANK RETROFIT, OR PIBT_NG REPAIR ?E.FLMZ"_' <br /> TiIS PERMIT EXPIRES 90 DAYS 'RCM T:{E APPROVAL DATE. 00 NOT WRITE IN ANY SHADED LEAS. =AICA S ?SUU%CT TY?E <br /> r; TANK R=.OFI: �' PIPING REPAIR <br /> EPA SITE VPr��10�ba ?ROSECr CONTACT TELEPHONE + �c � 2)MW11`ftJ-1 1 2' !�pZZ <br /> :AC_L:TY NAME�1,T Sv vasi =aNE 20� � 2- I(o2L <br /> C I koDREss (912o S4 f <br /> ;lass S'Marr W tscluan S[ E <br /> T INNER/OPERATOR ?CONS L'g7 yS <br /> Y I pLv6,T tyktcl b <br /> C =-%r,-AC OR NAME Gh{fie ?:eN Zcei S3`1 �1?.1(t. ! <br /> �'uM C� <br /> 'N I Isk0-ro-A vVE Corr CN ra Lac c_oN RAoR ADDRESS �o�� s �'! �� I <br /> C� - �IfF <br /> T j FCR.K =LIP.; Q� F.ae <br /> R I _NSURER <br /> A ' <br /> C I JTHER =NFORMATION I I <br /> 0 i I ?F?CNE d <br /> R i <br /> ?'JCNE # <br /> —-�IlllllllllTANK 'lDllllllllllllll TANK SI2. IG-EMICS[S STORED =R.RsYL[/?LrICCSLY ::A-,S US yrSTALLED <br /> 1 ,y- DOD (44- -e I Avu AT%;,g _�ra�, ML-L. t-rrlit_ i (A-A'j 191 <br /> T 1 39- <br /> A <br /> N I 39-_ I <br /> { 1 39- <br /> 39-- <br /> 39- <br /> [Jill 11111111111111111111111111111111111[111111111111111111111111111111111 11111111ill III I I <br /> 9-39- <br /> 39- <br /> i111111111111111111111111111111111111111[1111111111111111111111111111111111111I11111111111 <br /> A2PRCV= APPROVED WITH CONDI-=ON(S) ]T_SAPPROVF.D 1 <br /> A I (SEE A.T^.ACiM017 WITH CONDITIONS) 1 <br /> N 1 ?LLY REVIEWERS NAME <br /> Jill <br /> A 111111111IIfIl111i1111111111Jill III[ <br /> IlIIIlII1111111111IIl1lllllllllllilfi[1II1111Illllllltlllllllllllillllllfllllllllillll![Il <br /> APP'_-CANT MUST PERFORM ALL WORK �-N ACCORDANCE WI^.i s'AN .,"OAQIIIN CDFJN7"' ORDrNANCES, S"T?�T r.',WS, '.VD RC"�S AN Z:G'L.:.._--FS OF y <br /> S?ii iCAQUIN COUNT^:" PT BLIC HEAL 14 SERVICES. OWNER. OR LICENSED A=T�T's 3IGVATURE =Z'- =5 :.-�"s. ?.^•Iw+'Ja�;G: CER===' ---,IAT I:i <br /> 3ECM, <br /> ':FIE ?ERFORMANCS OF THE WORK -CR WHICH ':K_TTS ?_FiHIT FIS .SSUED, _ .icfi.Ls., NOT EMPLOY ANY ?E''SC:f .N au'CH A '+1..•1NE� AS .J OL <br /> SU3SWC TO WORKER'S =MP=_NSA-ION JAWS OF "AL:vORNIA.' CONTRAC'_'OR'S HIRING wR SUBCONTRACT-I.YG >>G1A� S CERTe IS T= ?GL OWING: <br /> _ �ERTI='Y THAT :V THE ?ERFORMANC; OF ..� 4CRK FOR WHICH THIS PERMIT IS ISSU`cD, I SHALL EMPLOY PERSCNS SL�zc- TO '+CRKER'S � <br /> CCMPENSATION LAWS OF R"fA..1 pppp r <br /> APPL:CaNT'S SIGN <br /> a <br /> BILGING INFORMA71ON: <br /> Indicace the responsible carte to be billed for additional ?F-S-M-M sta_- time amended beycnd <br /> pe=it payment coverage per tank. _Tf the party designated below :s dif-ferent than the permit <br /> applicant, e.g- property owner, the party must acknowledge this responsibility =,ter the billing <br /> by signature and data below. <br /> Name o�2 r 11 i t�0 address &izo ..{ , yr � =hone number 1 n <br /> pp Sian a <br /> ianaM1 <br /> l_J�.{V J�1 ti le,• <br /> COSS- Lff Ot CQO'a ' 1 .1cVIdtiJ <br /> EH ?3-0038 <br /> p <br />